Free Printable Back Pain Soap Note

Prepared by: [Your Name]

I. Subjective

A. Chief Complaint

• The patient reports persistent lower back pain for the past two weeks.

B. History of Present Illness (HPI)

• The pain started after lifting a heavy object at work.

• Described as a dull ache, occasionally sharp when bending or twisting.

• Pain level: 6/10 on a numeric pain scale.

• Worse with prolonged sitting or standing; improved with rest and heat application.

C. Past Medical History

• History of mild sciatica 3 years ago.

• No prior surgeries or major trauma.

D. Medications

• Currently taking over-the-counter ibuprofen (400 mg twice daily).

E. Additional Notes

• Denies numbness, tingling, or weakness in the legs.

II. Objective

A. Physical Examination Findings

• Inspection: No visible deformity or swelling in the lumbar region.

• Palpation: Tenderness over the L4-L5 region; no muscle spasms noted.

• Range of Motion: Limited forward flexion; extension and lateral movements are mildly painful.

• Neurological Exam: Normal reflexes, muscle strength, and sensation in lower extremities.

B. Diagnostic Tests

• None were conducted during this visit.

III. Assessment

A. Diagnosis

• Mechanical lower back pain, likely due to muscle strain.

• Rule out disc herniation or other underlying conditions.

IV. Plan

A. Treatment Recommendations

• Continue ibuprofen as needed for pain relief, up to 3 times daily.

• Apply a heating pad for 20 minutes, 2-3 times per day.

• Avoid heavy lifting and strenuous activities for the next 1-2 weeks.

B. Therapeutic Interventions

• Refer to physical therapy for strengthening exercises and posture correction.

C. Follow-Up

• Reassess in two weeks or sooner if symptoms worsen.

• Consider imaging (X-ray or MRI) if no improvement after four weeks.

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